Healthcare Provider Details

I. General information

NPI: 1346153236
Provider Name (Legal Business Name): LAKE AREA MEMORY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4313 BALL RD NE
CIRCLE PINES MN
55014-2209
US

IV. Provider business mailing address

4313 BALL RD NE
CIRCLE PINES MN
55014-2209
US

V. Phone/Fax

Practice location:
  • Phone: 763-344-7177
  • Fax:
Mailing address:
  • Phone: 763-344-7177
  • Fax: 763-355-6355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: GRACE FABRO
Title or Position: ASSISTANT DIRECTOR
Credential:
Phone: 763-344-7198